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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 01/11/2023
Date Signed: 01/11/2023 02:11:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/12/2022 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220912152327
FACILITY NAME:WINDCHIME OF CHICOFACILITY NUMBER:
045001959
ADMINISTRATOR:VONWAL, JEFFREYFACILITY TYPE:
740
ADDRESS:855 BRUCE RDTELEPHONE:
(530) 566-1800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:120CENSUS: 59DATE:
01/11/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Executive Dirctor: Jacob Primeau TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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- Staff mismanaged resident medication.
- Insufficient staffing to meet the needs of residents in care.
INVESTIGATION FINDINGS:
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On 01/11/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 09/12/2022. LPA met with Executive Director, Jacob Primeau, and explained the purpose of the visit. LPA ensured the following Personal Protective Equipment (PPE) was worn surgical mask. LPA were screened by facility staff and washed hands prior to entering the facility.

During the course of investigation, the Department interviewed facility staff and obtained pertinent documents relevant to the complaint investigation such as, resident’s (R1) physician’s report, medication administration records (MAR), physician/healthcare provider communication form, service plan, medication passing details, and dermatologist suspension order. R2's physician’s report, face sheet, appraisal, and staff schedules.

Continue on page LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 25-AS-20220912152327
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: WINDCHIME OF CHICO
FACILITY NUMBER: 045001959
VISIT DATE: 01/11/2023
NARRATIVE
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Allegation: Staff mismanaged resident medication. – Substantiated.

According to R1’s physician’s report, R1 is unable to administer own prescription medications, unable to administer own PRN medications, and unable to store own medications. The Department received and reviewed R1’s dermatologist suspension order for medication Triamcinolone. On 08/25/2022, medication was suspended. According to R1’s MAR, Triamcinolone was administered on 08/26/2022 and 08/27/2022 by facility Med-Techs.

Allegation: Insufficient staffing to meet the needs of residents in care. – Substantiated.

According to Complainant, there is only one (1) Med Tech scheduled to work at the facility for three (3) months. Complainant stated facility staff are forced to work longer shifts due to insufficient staffing. Residents in the Memory Care Unit are being neglected in their care. Showers aren’t being done. R2 is left sitting in their own urine and feces all morning. Care staff are asked to check on residents however they would ignore requests until someone of higher authority delegates them what to do.

According to R2’s physician’s report, R2 is diagnosed with Dementia and requires assistance with toileting. Facility staff is to assist R2 with bowel movement and bladder movement. R2 is not able to independently transfer to and from bed.

The Department interviewed at total of five (5) facility staff. Interview statement gathered from facility staff (S2) indicated, there were several occasions where R2 incontinence briefs were not changed. Based on condition of R2’s brief and bedding R2 was most likely left in urine for hours. This occurred during the NOC shift. S2 presume that NOC shift staff would wait until their end of the shift to change R2 or does not change R2 at all. S2 notified management and observed the issue getting addressed. According to S2, staff conduct rounds every thirty (30) minutes to check on R2. Each shift consists of three (3) to four (4) caregivers scheduled to work in the Memory Care side and four (4) caregivers scheduled for the Assisted Living side, one (1) Med Tech working per shift. S2 stated between January 2022 and September 2022 staff are frequently calling out sick so there would be two (2) caregivers working on Memory Care side and Assisted Living side. Interview statement gathered and received from S5, 56, and S7 were consistent with statement gathered from S2. Facility staff indicated they had observed R2 soaked in urine on multiple occasions. S7 indicated there is inadequate staffing due to staff call outs.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 25-AS-20220912152327
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: WINDCHIME OF CHICO
FACILITY NUMBER: 045001959
VISIT DATE: 01/11/2023
NARRATIVE
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The facility is currently on probation. According to Stipulation and Order adopted by the Department on 06/08/2022, Respondents shall strictly adhere to the resident and staff ratios and shall ensure that the facility is sufficiently staffed with caregivers to meet the needs of residents in care. Additionally, Respondents shall ensure that the facility is staff with the following minimum staff. The Memory Care Unit shall maintain a staff to resident ratio of 1:6 or more as needed to sure that residents’ needs are met. The Assisted Living Unit shall maintain a staff to resident ratio of 1:10 or more as needed to sure that residents’ needs are met. The Memory Care Unit shall maintain a staff to resident ratio of 1:11 or more as needed to ensure that residents’ needs are met during the right-on-call (“NOC”) shift. The Assisted Living Unit shall maintain a staff to resident ratio of 1:16 or more as needed to ensure that residents’ needs are met during the NOC shift. Only one (1) caregiver may be deemed a “floater” during the entirety of the NOC shift and be counted in the ratio of both the Memory Care Unit and Assisted Living for that shift. Respondents shall ensure that the caregiving staff’s other duties do not distract from caregiving, and that working in the capacity of caregiver does not distract from the staff’s primary duties. A Med Tech shall not be included in the direct care ratio when they are performing Med Tech duties.

The Department requested and reviewed the facility’s staff schedules. The facility’s census is 53. According to staff schedules, a total of three (3) caregivers and one (1) Med Tech are scheduled to work Assisted Living side and Memory Care side. A pattern of staff call outs are occurring on the staff schedule.

Due to this information CCL finds the allegation to be SUBSTANTIATED. – A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited on the attached LIC 9099-D.

Appeal rights were provided.

An exit interview was conducted, and a copy of the report left at the facility.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 25-AS-20220912152327
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: WINDCHIME OF CHICO
FACILITY NUMBER: 045001959
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2023
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be to assist the resident with self
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Executive Director agrees to conducted training on medication and provide CCL proof of training. ED is to include topics and staff must sign off on the training. ED is to submit staff training to CCL by POC due date, 11/18/2023.
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administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidenced by: Based on documentation review facility staff administered suspended medication to R1. This poses an immediate health and safety risk to resident in care.
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Type A
01/18/2023
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608 ...
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Exectuive Director is to provide a detailed plan explaining how they will ensure facility staff are competent and aware of how to properly provide care and provide supervision to residents in care in writting and submit to CCL by POC due date, 01/18/2023.
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The licensing agency may require any facility to provide additional staff... arrangements of the facility require such additional staff for the provision of adequate services. Based on documentation and interview, facility did not ensure R2's needs were met which poses an immediate health and safety risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4